One thing that surprises young doctors fresh out of residency is just how often they themselves get sick — mostly with colds and cough illnesses — as a result of taking care of sick patients. If you think about it, this shouldn’t be surprising at all! Especially for those who practice primary care medicine (and especially those in pediatrics), exposure to all sorts of contagious viruses, bacteria, fungi, and parasites is a daily (maybe hourly) occurrence. Despite practicing what we preach by washing our hands frequently, it is likely that your child’s runny nose, cough, pink eye, vomiting, or diarrhea will, in the next few days, become our symptoms. It’s not just physicians, nurses, medical assistants, nurse practitioners, and physician assistants who work on the “front lines” of patient care who bear the risk. The rest of our office staff are also in the line of fire simply by spending eight hours a day working in the same office space that sick people visit, even if they don’t actually come in direct contact with them.
Most of us understand these risks — and come to work anyway! But what happens when a doctor (or a nurse practitioner or medical assistant) are sick themselves? The last thing a patient, or the parents of a patient, expect is for them to pick up a contagious infection from their health care provider who comes to work sick. According to a new study, published this week in JAMA Pediatrics, pediatric health care workers are doing just that. Researchers surveyed physicians and advanced practice clinicians (like nurse practitioners, physician assistants, and nurses) at a large Philadelphia children’s hospital and found that 83% of them had come to work sick in the past year. Even worse, 95% of responders did so even though they knew it put their patients in danger. Alexandra Sifferlin cites some reasons why:
Most respondents said they would work while sick because they didn’t want to let their coworkers down. Others cited staffing concerns, not wanting to let down their patients or fear of being “ostracized” by their peers in the hospital.
In an editorial in the same journal, doctors Jeffrey R. Starke and Mary Anne Jackson explain:
More than 80% of respondents had worked with patients while sick; many pointed to a personal moral obligation they feel to the patient and a desire to avoid burdening colleagues but also identified a system that increasingly emphasizes productivity. The authors identified the following 3 issues: policies and logistic issues that do not support appropriate absenteeism from work, cultural norms that discourage HCW absenteeism, and the ambiguity felt by HCWs regarding what constitutes being too sick to work. Most of the respondents recognized the cognitive dissonance of knowing their illness might have an adverse effect on patients but also not wanting to let colleagues down (97.2%) or to create staffing shortfalls (94.2%).
The authors tackle the question: “How sick is too sick?”:
The degree and duration of contagion and the potential adverse effect on the patient population are important. Using a system that bases work restrictions on the presence of key symptoms may add clarity for HCWs to recognize when they need to stay home (eg, conjunctivitis, vomiting, bloody diarrhea or >2 episodes of watery diarrhea, jaundice, fever of >38.5°C). For many respiratory viruses, individuals are most contagious before they are highly symptomatic,5 so staying home after symptoms develop may not be effective or practical. The role of barrier precautions worn by ill HCWs during patient interactions should be investigated more thoroughly. Institutions should develop policies and programs that allow temporary replacement of even mildly ill staff who care for high-risk patients.
This problem is not unique to pediatrics, to primary care, or even to the medical profession. I’d bet most adults who work outside the house “suck it up” and go to work when they are feeling sick, especially when they, too, are compensated based on their attendance and productivity, as well as by the frequency with which they burden other workers who are called to fill in or replace them when they are absent.
Telling adults to stay home from work when they are sick is easier said than done — for all of us.